ncpa immunization course module 4 - CE...

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Module 4: Communication and Counseling – The Patient’s Immunization Experience

Jonathan G. Marquess, PharmD, CDE, CDM

Creating an Immunization Niche in the Community Pharmacy

Learning Objectives

• Discuss the set up of the administration area for a vaccine practice.

• List and discuss proper questions to have vaccination patients complete prior to receiving a vaccination

• Discuss counseling and storage tips for 3 commonly given vaccinations

• Review appropriate pharmacy procedure following patient vaccination

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Pre-Assessment Question #1There is a legal requirement in a vaccine niche to:

• A. Have the patient sign a release or waiver.• B. Distribute a vaccination information

statement• C. Keep the patient under observation for 30

minutes following immunization• D. All of the above

Correct Answer

There is a legal requirement in a vaccine niche to:

• B. Distribute a vaccination information statement

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Pre-Assessment Question #2

The vaccine administration area must be a certain size and have particular requirements by law.

A. TrueB. False

Correct Answer

The vaccine administration area must be a certain size and have particular requirements by law.

• B. False

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Pre-Assessment Question #3

Pharmacists in most states are restricted from giving immunizations to which population group:

• A. Adults• B. Pediatric patients• C. Nursing home residents• D. None of the above

Correct Answer

Pharmacists in most states are restricted from giving immunizations to which population group:

• D. None of the above

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Creating a Patient-Focused Immunization Area

Creating a Patient-Focused Immunization Area

• Administration area• Vaccination counseling information

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Administration Area

• Identify a location in your pharmacy where patient privacy can be maintained

• Seated area (chair with arms) is preferred• A small worktable is also helpful• For vaccine events, a waiting area is

preferable

Picture of Administration Area

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First Impressions

• Greeting the patient – Staff should be assigned to greet the patient

and direct them to the immunization area– Staff should be prepared to answer any

questions• Have patient complete patient intake form

Patient Intake Form

• Give your patients a detailed form to assess patient health status

• Form should contain– Primary care physician contact information– Any allergies etc.

• Patient should read it over and sign prior to immunization

• Staff should identify any problems and discuss

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Sample Patient Intake Form

Vaccine Information

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Two Types of Vaccines• Live Attenuated

– Produced by modification of wild virus or bacteria– Has ability to replicate and produce immunity– Usually does not cause disease– Effective with one dose; exception –oral live

attenuated vaccines– Can cause severe or fatal reactions

• Inactivated– Produced by growing then inactivating virus or

bacteria with heat or chemicals– Are not alive, therefore, cannot replicate– Require multiple doses and “boosters”

Routine Adult Community Pharmacy Vaccines

“The Flu Shot” - Influenza“Shingles” - Herpes Zoster

“Pneumonia” - Pneumococcal

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Trivalent Inactivated InfluenzaVaccine (TIV) Overview

• Regimen: – Yearly administration for all persons > 6

months• Administration:

– IM• Shelf life:

– Formulated for use during current influenza season only

• Storage: – Refrigerate immediately upon arrival– Do NOT freeze

Trivalent Inactivated InfluenzaVaccine (TIV) Counseling Tips

• Preferred influenza vaccine for pregnancy and many underlying medical conditions

• Contraindications: – Previous anaphylaxis to this vaccine or to

eggs• Precautions:

– Moderate or severe illness – History of Guillain-Barré syndrome within six

weeks of previous influenza vaccination

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Guillain-Barré Syndrome (GBS)

• Neurologic disorder involving inflammatory demyelination of peripheral nerves

• Characterized by the following:– Symmetrical weakness in the legs and arms, with

loss of reflexes– Sensory abnormalities– Involvement of cranial nerves– Paralysis of respiratory muscles also can occur

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Live Attenuated InfluenzaVaccine (LAIV) Overview

• Regimen: – Yearly administration for all persons > 2 years old

• Administration: – Each pre-filled nasal syringe contains 1 dose – Deliver ½ dose into each nostril

• Shelf life: – Formulated for use during current influenza season

only

• Storage: – Refrigerate immediately upon arrival– Do NOT Freeze

LAIV Administration

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Live Attenuated InfluenzaVaccine (LAIV) Counseling Tips• Contraindications:

– Previous anaphylaxis to this vaccine or to eggs– Contraindicated in pregnancy, pulmonary or

cardiovascular disease, diabetes, asthma and many other underlying medical conditions

• Precautions– Moderate or severe illness – History of Guillain-Barré syndrome within six weeks of

previous influenza vaccination

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Zoster (Shingles) Overview

• Regimen: – Single dose for adults > 60 years old

• Administration: – SC - deltoid region of the upper arm, if

possible • Storage:

– Freeze immediately upon arrival

Zoster (Shingles) Counseling Tips

• Not for use in the treatment of active zoster outbreak or postherpetic neuropathy (PHN)

• Contraindications: – Hypersensitivity to vaccine components– Anaphylactoid or hypersensitivity reactions to

neomycin or gelatin– Immunosuppression

• Precautions: – Acute illness

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Pneumococcal Polysaccharide Vaccine (PPV) Overview

• Regimen:– Variable depending on health status

• Administration: – IM or SC


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PPV Counseling Tips

• Contraindications:– Previous anaphylaxis to this vaccine or to any

of its components• Precautions:

– Moderate or severe acute illness

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Interactive Checkpoint

• Sally, a 65 year old woman, comes into your pharmacy for a zoster vaccine. When she completes her patient intake form, you notice an allergy to Neosporin. Should you proceed with administering the vaccine?

A. YesB. NoC. Maybe


• Maybe– If the prior allergy was contact dermatitis, it

may be ok to administer this vaccine – Consult Sally's physician prior to

administration

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Other Adult and Adolescent Vaccines

Hepatitis A (HepA) Overview

• Regimen:– One dose and one booster 6 to 18 months

later• Administration:

– IM into deltoid muscle of the arm• Storage:

– Refrigerate immediately upon arrival– Do NOT freeze

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Hepatitis A Counseling Tips• Contraindications:

– Hypersensitivity to vaccine or any of its components.

• Precautions: – Hepatitis A has an incubation period of 15-20

days. The vaccine may not protect the individual if administered in this time period.

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Hepatitis B (HepB) Overview

• Regimen: – Doses are given at 0, 1, and 6 months

• Administration: – IM into deltoid muscle of the arm


Hepatitis B (HepB)Counseling Tips

• First dose is given at birth for children of all Hepatitis B + mothers or unknown status

• A patient is given the pediatric dose until age 19• Contraindications:

– Hypersensitivity to yeast

• Precautions: – Multiple Sclerosis – Immunosuppression

• All formulations are “without preservative”

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Hepatitis A & Hepatitis B (HepA/HepB) Overview

• Regimen: 1ml doses– Primary Immunization: doses at 0, 1 and 6 months – Alternative Schedule: doses on days 0, 7, 21, and 30

with a booster dose at 12 months

• Administration: – IM into deltoid muscle of the arm


• Shake well and do not dilute

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HepA/HepB Counseling Tips

• Contraindications: – Hypersensitivity to yeast or neomycin

• Precautions: – Long incubation periods

Tetanus, Diphtheria, & Acellular Pertussis (Tdap) Overview

• Regimen: – One 0.5 ml Tdap and booster every 10 years up to

age 64• Administration:

– IM into deltoid muscle of the arm• Storage:


• Shake well

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Tdap Counseling Tips• Contraindications:

– Encephalopathy within 7 days of a previously administered Tdap vaccine with no other discernable cause

– Progressive neurological disorders, uncontrolled epilepsy or progressive encephalopathy

• Precautions:– Within temporal relationship to previous Tdap

dose:• Fever over 105° F, inconsolable crying over 3 hours, or

collapse or shock-like state within 48 hours• Seizures within 3 days• Guillain-Barré syndrome within 3 weeks

– Stable CNS disorder patients

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Human Papillomavirus (HPV) Overview

• Regimen: – Females ages 9-26 = 0.5 mL at 0, 2, and 6

months• Administration:

– IM• Storage:


Human Papillomavirus (HPV) Counseling

• Provides protection against four strains of HPV

• Contraindications: – Hypersensitivity to papillomavirus

recombinant vaccine or any component of the formulation

• Precautions:– Acute illness – Bleeding disorders

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Meningococcal Vaccine (MCV) Overview

• Regimen: – Give one dose to adolescents age 11 through

18 years • Administration:

– MCV4 (conjugate) - IM– MPSV (polysaccharide) – SC


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MCV Counseling Tips• Required vaccination for travel to many

areas including Saudi Arabia during the annual Hajj

• Contraindications: – Previous anaphylaxis to this vaccine or to any

of its components, including diphtheria toxoid (for MCV4)

• Precautions: – Moderate or severe acute illness.– For MCV4 only: history of Guillain-Barré

syndrome

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Travel Vaccines

Japanese EncephalitisTyphoid FeverYellow Fever

& More

Travel Vaccine Documentation

• The CDC has released a new International Certificate of Vaccination or Prophylaxis (ICVP)

• This document is designed to fit into your passport

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Travel Vaccines by Country

• CDC website provides an interactive world map to help determine which vaccines are recommended for various countries

• http://wwwn.cdc.gov/travel/destinationList.aspx

Japanese Encephalitis Overview

• Regimen: – 3 dose series – days 0, 7,and 30

• Administration: – SC

• Shelf life: – Use within 8 hours


• Shake well

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Japanese Encephalitis Counseling Tips

• Receive if:– Reside or travel where endemic or epidemic– Generally 1 month or longer stay

• Must receive last dose 10 days before travel.– Stay in the area (no international travel) for 10 days post

vaccination• Not for infants < 1 year old• Contraindications:

– Prior angioedema or urticaria to vaccine– Hypersensitivity to thimerosal

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Rabies Overview• Regimen: 3 doses

– Dose 1 - as appropriate– Dose 2 - seven days after dose 1– Dose 3 - 21 or 28 days after dose 1

• Administration: – IM

• Storage: – Refrigerate immediately upon arrival – Do NOT freeze

Rabies Counseling Tips• Preexposure vaccination is recommended for

persons in high-risk groups, such as veterinarians, animal handlers, and certain laboratory workers

• Contraindications: – Hypersensitivity to vaccine or component– Developing febrile illness

• Precautions:– Vaccination should be repeated after exposure with

rabies immune globulin– Bleeding disorders– Immunocompromised patients

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Typhoid Fever Overview• Required:

– Travel to locations with recognized risk– Intimate contact with infected individuals– Microbiology lab workers

• Administration: – IM – PO

• Storage: – Keep both versions in the refrigerator – Do NOT freeze– Must replace PO capsules into refrigerator after removing a

capsule

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Typhoid Fever Counseling Tips• Typhim Vi®

– IM – Give 2 weeks prior to

exposure– Reimmunize in 2 years

• Contraindications:– Hypersensitivity to

components• Precautions:

– Not protected against other types of Salmonella

– Not for chronic carriers

• Vilvotif®– PO – 4 doses on days 1,3,5,&7– Complete 1 week prior to

exposure– Must give 1 hour pre-meal

with cold/warm drink• Contraindications:

– Hypersensitivity– Immunosuppression

• Precautions:– Acute GI illness– No antibiotics or

sulfonamides– Postpone vaccine if

patient has significant diarrhea or vomiting

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Yellow Fever Overview• Regimen: 0.5 ml for ≥ 9 months of age

– Re-immunization is required every 10 years• Receive if:

– Yellow fever has been reported in area you are visiting.– If you are traveling outside urban areas– African countries may require– May need certificate of vaccination to pass through other countries

• Administration: SC • Must reconstitute. Will be orange in color.

– Do NOT shake! Swirl Instead to avoid air bubbles• Shelf Life:

– Use within 60 minutes of reconstitution– Does NOT contain a preservative

• Storage:– Refrigerate immediately upon arrival– Do NOT freeze

Yellow Fever Counseling Tips• Contraindications:

– Under 9 months – Hypersensitivity to gelatin, eggs, or egg products– Immunosuppresed

• Precautions:– Do a scratch or intradermal test to determine if vaccine

is okay if the patient is egg sensitive– Corticosteriod therapy may decrease effect– Asymptomatic HIV patients must document protective

antibody response before traveling

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Malaria Overview and Counseling

• Drugs used to prevent malaria (chemoprophylaxis) – oral meds only!– Chloroquine (Aralen®)– Mefloquine (Lariam®)– Atovaquone/Proguanil (Malarone®) – Doxycyline

• Proguanil cannot be administered within 10 days of typhoid vaccine

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• Just as a refresher, which of the following vaccines is live?

A. Pneumococcal polysaccharide vaccine B. Human Papillomavirus (HPV) VaccineC. LAIV influenza vaccineD. Meningococcal vaccine


• LAIV influenza vaccine– Remember when counseling your patients

that they may produce a mild version of the flu.

– Exercise caution when around immunocompromised individuals because they could contract the disease.

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Childhood Vaccines

Childhood Vaccines Overview

• Some community pharmacist offer childhood vaccines in the community pharmacy

• Many pharmacists prefer the role of advocate for children

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Vaccines for Children

• Hepatitis B• Rotavirus• Diphtheria, Tetanus,

Pertussis (Dtap)• Haemophilus

influenzae type b (Hib)

• Pneumococcal conjugate

• Inactivated Poliovirus

• Influenza• Measles, Mumps,

Rubella (MMR)• Varicella• Hepatitis A• Meningococcal

Vaccines and Autism• Some advocates claim that vaccines and

thimersol cause autism• Since 2001, with the exception of some

influenza vaccines, thimerosal is not used as a preservative in routinely recommended childhood vaccines

• As of yet, there has been no decrease in autism rates

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• Mary brings in her daughter, Lauren aged 6 months, into the pharmacy for a prescription of amoxicillin suspension. What vaccines should you ask if Lauren has received?


• Hepatitis B, Rotavirus, DTaP, Hib, PCV, and IPV.

• Are they other vaccines that should be recommended today?

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• At six months, Lauren would be due for another round of rotavirus, DTaP, Hib, and PCV. – Hepatis B, IPV and influenza are in the range

also

Vaccine Administration

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Sites of Administration• Subcutaneous (SC)

– MMR– MPSV4– Varicella– Zoster

• SC & IM– PPV– IPV

• Oral– Rotavirus

• Intranasal– LAIV

• Intramuscular (IM)– All DTaP formulations– Tdap– Hib– HepA– HepA/HepB– HepB– Hib/HepB– HPV– TIV– MCV4– PCV

SC Needle Specs

• Use a 23-25 gauge needle• Choose the injection site that is appropriate to

the person’s age and body mass

Fatty tissue over anterolateral thigh muscle or fatty tissue over triceps

5/8”Children (> 12 months), adolescents & adults

Fatty tissue over anterolateral thigh muscle

5/8”Infants (1-12 months)

Injection SiteNeedle Length

Age

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IM Needle Specs

Deltoid muscle of armDeltoid muscle of armDeltoid muscle of arm

5/8” – 1” 1” – 1 ½”1 ½”

>19 yrs (sex/weight)Male/Female < 130 lbs

Female (130-200 lbs)/Male (130-260 lbs)Female > 200 lbs/Male > 260 lbs

Deltoid muscle of arm or anterolateral thigh muscle

5/8” – 1” 1” – 1 ¼”

Children (3-18 years)

Anterolateral thigh muscle or deltoid muscle of arm

1” – 1 ¼”5/8” – 1”

Toddler (1-2 years)

Anterolateral thigh muscle

1”Infant (1-12 months)

Anterolateral thigh muscle

5/8”Newborn (1-28 days)

Injection SiteNeedle Length

Age

Administration Sites

Anterolateral Thigh Muscle

Deltoid Muscle

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Post Vaccination

Patient Monitoring Post-Vaccination

• Make sure patient is aware that they will need to spend 15-20 minutes in the pharmacy following their vaccination

• Assign staff member to notify patients when their monitoring period has ended

• Notify patients that they can call pharmacy with questions or concerns after leaving the pharmacy

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Possible Post-VaccinationAdverse Events

• Local reactions– Redness– Inflammation– Pain at site of

injection– Muscle ache– Contact dermatitis

• Systemic reactions– Fever– Malaise– Fatigue– Anaphylaxis

• Swelling• Respiratory distress• Itching• Vomiting• Hypotension• Abdominal pain

Possible Post-VaccinationChildren Concerns

• Fever– Reduce the fever by fluids, fever-reducing

medication (not aspirin) and lukewarm baths• Discomfort

– May be due to pain or fever– Call pediatrician if persists more than 24 hours

• Swelling– Apply a clean, cool, wet washcloth over the sore

area for comfort– Call pediatrician if persists more than 24 hours

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Adverse Events –When to Refer

• If side effect persist more than 24 hours, refer to primary care physician or pediatrician

Follow-Up

• Patient – Assess adverse events

• Physician– Update vaccination records

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Conclusion

• Giving vaccinations in your community pharmacy requires both front end intake procedures and good follow up

• You can have a vaccine niche that covers as little or as much as you are prepared to cover from flu to travel and adolescent vaccines

• Each vaccination has specific storage, handling and counseling requirements

ncpa immunization course module 4 - CE...

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